Help with sundowning residents (long)

[Elektra6, ASN, BSN, RN]

I'm a new nurse (7 months) I started working the 3-11 shift recently and the first few hours of my shift have been pure hell lately. I have one resident in particular who becomes agitated and every day is looking for her parents, brother, husband, etc., and frequently escalates into violent behavior. She shouts and screams at other residents and throws things and rips stuff off the walls. She won't leave me or the other staff alone. She tries to rally the other residents to help her and then becomes angry at them. Day shift doesn't address the problem because she's not usually like this on their time.

Another resident complains of SOB & CP constantly, but her vitals are always fine. She's been worked up extensively. Her O2 sat is a little low but if you give her oxygen she'll take it off and then scream she can't breathe. She made herself a DNH. I have tried to placate her, give her extra attention, ignore her, been firm with her, but NOTHING works. She'll come to me more than 30x a shift. It also looks terrible to visitors and other staffers to see a nurse ignoring a resident complaining of CP or SOB.

I just need some tips for dealing with these residents because nothing I do seems to work (except PRNs which they won't take if agitated anyway).

Help, I'm ready to quit because I'm afraid I'll lose it and yell at the resident or another person on staff. It's been really hard to not lose my patience.

Any tips would be a lifesaver. Thanks.

[UM Review RN, ASN, RN]

Sounds like you need to call the doc on Resident #1 and ask for some type of medication that you can give her before she escalates. In my state, the only way to justify continuing a patient on this type of medication is to document the heck out of every single behavior episode.

You need to make a graph with time/type of the behaviors she's demonstrated throughout your shift--restlessness, agitation, pacing, fingerpointing, yelling at staff, yelling at other residents, throwing things, hitting, etc, and document the number of times that she does these things during your shift. Don't neglect to add what type of intervention you tried to distract or change the behavior, along with the patient response.

With the next resident, you will have to get some backup from your supervisor, but if a patient comes to you c/o SOB and does have low O2 sats, what else can you do but offer to send her to the hospital? If she refuses, then suggest to her that maybe she doesn't feel so bad after all? Because if she IS feeling that badly, you HAVE to send her to the ER.

Who knows, she might be short of breath because she has a heart dysrhythmia or something that the usual set of vitals cannot tell. Also, it might be interesting to note if this behavior occurs after meals. Still, if any resident came to me more than 3 times in one shift c/o chest pain and shortness of breath, they'd be off to the ER for (yes, another!) workup.

Because even though you think she might be crying wolf this time and several hundred other times, one of these days, she won't be. If the doc is truly convinced that she has nothing wrong except anxiety, he needs to prescribe something for her along those lines. But the patient is disruptive, if nothing else, and needs SOME kind of treatment.

Please let us know what you do and how it works.

[vloho]

I second that emotion

[HannasMom]

I agree with Angie.

[Daytonite, BSN, RN]

Contestant #1 needs a psych eval.

Contestant #2 needs some pain medication or a psych eval too.

I wouldn't depend on the day shift to do these things. I'd pick up the phone and call the docs of these patients the first thing coming on shift. Oh, you probably also need to talk to the patient's families as well, too, and let them know what you are doing. Make sure you are documenting all this behavior.

[UM Review RN, ASN, RN]

Contestant #1 needs a psych eval.

Contestant #2 needs some pain medication or a psych eval too.

I wouldn't depend on the day shift to do these things. I'd pick up the phone and call the docs of these patients the first thing coming on shift. Oh, you probably also need to talk to the patient's families as well, too, and let them know what you are doing. Make sure you are documenting all this behavior.

Another great idea. I second that!

[indigo girl]

Another great idea. I second that!

Agree with all the above.

Also, want to extend my sympathy to you. Your shift is a tough one what with visitors and families adding to the disruption. Don't give up, but do get on that phone. It's the only way anything is going to change. Keep us posted.

[lovingtheunloved, ASN, RN]

Resident #1's parents, brother, whoever went shopping. They'll be back in a few hours. If she wants to destroy things, take her to her room, give her a bunch of linen, paper, whatever, let her go to town. Maybe she'll make a mess, a lot of the time when the resident thinks the acting out doesn't bother you, they have no more reason to act out. As far as not leaving the staff alone, have a staff member (activities staff is good for this) do one on one with her, help her destroy stuff, whatever.

Resident #2 needs to be involved in an activity at the first sign of anxiety. Get her busy so she'll forget she's obsessed with chest pain.

And I'm a firm believer in ambulating everyone who is in a wc around 1500. They spend all that time on their butts and that energy builds up and they don't know what to do with it. Getting them up and moving really helps ease the anxiety that causes those behaviors.

And, of course, there's always the distinct possibility that none of what I said will work. That's dementia for ya!

[hopefullpn07]

Try to get them involved with an activity that is going on in your shift, sometimes a distraction works. Also get your social worker at your facility involved, a behavior sheet to record the violent acts, that way if a psych eval is needed you have documentation to back you up.

[joyflnoyz, LPN]

I agree with the psychiatric consult idea, for both resddents.

I had one similiar to #1...every evwening, she would become very anxious, and tell everyone her father was looking for her. My response was

"I haven't seen him, but when I do I'll tell him you are looking for him, and where you are." That would settle her right down. I took her concerns seriously.

One time a nurse I worked with told a patient her mother had gone shopping.

Pt's response? "Oh no, she never goes shopping without father, and he's right over there. Something mut have happened to her! " (paraphrased) Increased anxiety!!!

I like angie's idea of the graph...I'll think I'll take that one and run with it.

[weirdRN, RN]

I have the nearly very same problem. I have four residents that have sundowners really bad. According to staff that has been there longer than me, all of them quiet down and usually go to sleep by seven.

So from 2:30 until 7 is pure H-e-double hockey sticks! I have several bruises and scratches from these residents.

[LoriAlabamaRN]

Boy, have I been there!

For the first resident, the doc can prescribe something scheduled for afternoons, we have some residents on psych meds for sundowning, but there are many choices and it may take some experimenting on the MD's part. It's sad, because the sundowner is honestly scared, mad, whatever and really needs something to help.

As for the second resident, it sounds like severe anxiety. Does she have any PRN meds for anxiety? Anxiety attacks are miserable and frightening. If her O2 is fine and EKG isn't worrisome, that might be all she needs.

Don't get me wrong, I don't automatically think a pill is the answer to everything, but it seems like in this situation it might be. The important thing is the resident's comfort.